Infant Mortality Is a Misleading Statistic for International Comparisons

There has been a long line of critics of American health care claiming that international comparisons of life expectancy and infant mortality rates provide supposedly irrefutable proof of the need for more government control of our health care system.

Los Angeles Times writer Michael Hiltzik recently echoed such assertions to conclude that “the U.S. stinks” in those areas. Unfortunately, though, infant mortality and life expectancy comparisons stink as health care efficiency indicators.

Using infant mortality as a condemnation of American health care not only ignores important differences in what countries count as infant deaths, it ignores many factors unrelated to health care quality that would dramatically change comparisons.

Nonviable babies who die quickly after birth are recorded as live births in the US, but are more likely to be classified as stillbirths in other countries, particularly if they die before birth is legally registered. That biases our infant mortality rate substantially upward compared with others. One study in Philadelphia concluded that the overstatement was 40 percent.

American doctors also go to greater lengths resuscitating very premature babies who are not breathing when they are delivered. This also means that babies at very high risk are counted as live births here, but not in many other countries, increasing our infant mortality rate as well as inflating our costs by increasing neonatal care needs.

Infant mortality also reflects many factors apart from health care provision, including mother’s age, obesity, drug use and other lifestyle factors, as well as babies’ gestational age at birth, all of which worsen American results.

The US has the highest proportion of preterm and low-birth-weight babies, which comprise a large fraction of infant deaths, of any developed country. For example, teenage mothers (nearly three times more common in the US than Canada and seven times more than in Sweden and Japan) are far more likely to have low-birth-weight babies. If the US birth-weight distribution had been the same as for Canada, a study found that, by itself, would lower American infant mortality below Canada's. A study of gestational ages found that if that distribution had been the same in the US as Sweden, it would cut our infant mortality rate one-third, making us equal to France.

Beyond overstated infant mortality measures, US life expectancy numbers are reduced by higher rates of death from violence and accidents in the US than other countries, even though it is not a reflection of the quality of our health care. They occur disproportionately at younger ages, which could largely be controlled for by using life expectancies starting at later ages, but OECD data relies on life expectancy at birth. For example, in 2000, female life expectancy at birth was 1 year higher in the UK and 1.9 years higher in Germany, but beginning at age 65 there was no differential with the UK and only 0.6 years with Germany.

Larger, more diverse countries also tend to have worse life expectancy results than smaller, more homogeneous countries, where communication problems, cultural differences, variance in population characteristics, etc., are far smaller. Further, what works for small, compact populations may not scale to far larger countries. As critics often repeat, the US ranks down the list in life expectancy, but what they never mention is that no country more populous than the US ranks higher. In fact, you could add up the populations of half of the countries in the top 10 of life expectancy in 2012 (e.g., Iceland, Monaco, and Andorra) without totaling California’s population.

The US is also very ethnically diverse (including more whites and more Hispanics than any other country, and with the 9th most black residents) compared to other countries. If we excluded blacks, who have far lower life expectancies both here and elsewhere, from the data, more closely representing the greater ethnic representation here, life expectancy would roughly equal the EU average. And perhaps most importantly, as Scott Ehrlich reported last year, while our “official” life expectancies lag many other countries, “on average, there is nowhere you will live longer in the world as someone of Asian, Hispanic, or African descent, than in the United States.”

Critics constantly use infant mortality and life expectancy comparisons as weapons to attack the US as offering inferior health care and push for ever-more government control. However, reported infant mortality and life expectancy data does not demonstrate that “the U.S. stinks” in health care provision, because they involve simplistic comparisons of inconsistent measures, which omit many important determinants. And while American health care here is an incredibly heavily regulated industry, whose resulting deviations from freely-made market arrangements cause real problems that need to be reformed by reducing rather than increasing government’s heavy hand, the supposedly “slam dunk” evidence critics constantly repeat provides no more proof of their claims than a higher than average death rate in an elite hospital that takes the riskiest patients proves it is a low-quality hospital.

Gary M. Galles is a professor of economics at Pepperdine University. He is the author of The Apostle of Peace: The Radical Mind of Leonard Read.